CMS/EIP Fiscal Report Center: 55
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.829867 212.2400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 30.666667 2300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 11.044666 828.3500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 20 60.541200 4540.5900 75.0000
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Total 60.541200 4540.5900 75.0000
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Number of Children (Unduplicated) With at Least One Service 20
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Center 55
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5 10.000000 750.0000 750.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 16.000000 1200.0000 0.0000
T 0 0.000000 0.0000 0.0000
21 34.541200 2590.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 34 60.541200 4540.5900 750.0000